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Concepts and Principles ofQuality ImprovementBruce D. Agins, MD MPHHEALTHQUAL; Institute for Global Health SciencesUniversity of California, San Francisco

The “know-do” gap“Health care interventions that are known to work and save lives arenot being implemented for every patient every time. We must addressthis gap between knowing and doing.”What we knowThe know-do gap – how what weknow differs from what we doWhat we doWe need to do the right things, in the right places, at the right time.2UCSF-HEALTHQUAL

Closing the “know-do” gap3Source: Project Fives Alive!

Count of observationsQuality assurance vs. quality improvementPerformance4UCSF-HEALTHQUAL

Count of observationsQuality assurance—pruning the “bad apples”Performance5UCSF-HEALTHQUAL

Count of observationsQuality improvement—reducing variationPerformance6UCSF-HEALTHQUAL

Count of observationsQuality improvement—moving the curvePerformance7UCSF-HEALTHQUAL

Count of observationsQuality improvement—putting it all togetherPerformance8UCSF-HEALTHQUAL

Seminal figures in QI historyWalter ShewhartVariation & PDSA9Quality Improvement: A RefresherW. Edwards DemingTQM and CQIJoseph JuranJuran TrilogyMasaaki ImaiKaizenAvedis DonabedianHealthcare quality

Contemporary QI Opinion LeadersDon BerwickIHI10Quality Improvement: A RefresherPaul BataldenDartmouthBrent JamesIntermountain HealthMary Dixon-WoodsCambridge UniversityAtul GawandeHaven

Quality improvement principlesFundamental concept of improvement:“Every system is perfectly designed to achieve exactly the results itachieves.”Principles of improvement:1. Understanding work in terms of processes and systems2. Developing solutions by teams of providers and patients3. Focusing on patient needs4. Testing and measuring effects of change5. Peer learning11Quality Improvement: A Refresher

Quality improvement principlesFundamental concept of improvement:“Every system is perfectly designed to achieve exactly the results itachieves.”Principles of improvement:1. Understanding work in terms of processes and systems2. Controlling and managing variation3. Developing solutions by teams of providers and patients (rootcause analysis; process investigation)4. Focusing on patient needs5. Testing and measuring effects of change6. Peer learning12Quality Improvement: A Refresher

QUESTION: In which discipline did QI start?A.B.C.D.E.13Laboratory scienceAutomobile manufacturingHealth careStatisticsCommunicationQuality Improvement: A RefresherWalter Shewhart

QUESTION: In which discipline did QI start?A.B.C.D.E.14Laboratory scienceAutomobile manufacturingHealth careStatisticsCommunicationQuality Improvement: A RefresherWalter Shewhart

Quality improvement principlesFundamental concept of improvement:“Every system is perfectly designed to achieve exactly the results itachieves.”Principles of improvement:1. Understanding work in terms of processes and systems2. Controlling and managing variation3. Developing solutions by teams of providers and patients (rootcause analysis; process investigation)4. Focusing on patient needs5. Testing and measuring effects of change6. Peer learning15Quality Improvement: A Refresher

TB Treatment Completion Rate10090Performance Rate (%)80706050p 0.001403020100Jan-0916Quality Improvement: A RefresherMaySepDecJan-10MaySepDecJan-11MaySepDec

TB Treatment Completion Rate10090Performance Rate (%)80706050403020100Jan-0917Quality Improvement: A RefresherMaySepDecJan-10MaySepDecJan-11MaySepDec

TB Treatment Completion Rate10090Performance Rate (%)80706050Also p 0.001403020100Jan-0918Quality Improvement: A RefresherMaySepDecJan-10MaySepDecJan-11MaySepDec

TB Treatment Completion Rate10090Performance Rate (%)80706050403020100Jan-0919Quality Improvement: A RefresherMaySepDecJan-10MaySepDecJan-11MaySepDec

10090Performance Rate (%)8070605040302010020Quality Improvement: A RefresherTB Treatment Completion Rate

10090Performance Rate (%)8070605040302010021Quality Improvement: A RefresherNew TB Treatment Completion Rate

Quality improvement principlesFundamental concept of improvement:“Every system is perfectly designed to achieve exactly the results itachieves.”Principles of improvement:1. Understanding work in terms of processes and systems2. Controlling and managing variation3. Developing solutions by teams of providers and patients (rootcause analysis; process investigation)4. Focusing on patient needs5. Testing and measuring effects of change6. Peer learning22Quality Improvement: A Refresher

Systems thinking astructureMaterialsInformationTechnology What is done How it is doneResults(Outcomes Health servicesdelivered Changes inhealth behavior Changes inhealth status PatientsatisfactionSource: Donabedian, A. Explorations in Quality Assessment and Monitoring Vol. 1. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health Administration Press, 1980.

Systems thinking astructureMaterialsInformationTechnology What is done How it is doneQuality Improvement: A RefresherResults(Outcomes Health servicesdelivered Changes inhealth behavior Changes inhealth status Patientsatisfaction

Quality improvement principlesFundamental concept of improvement:“Every system is perfectly designed to achieve exactly the results itachieves.”Principles of improvement:1. Understanding work in terms of processes and systems2. Controlling and managing variation3. Developing solutions by teams of providers and patients (rootcause analysis; process investigation)4. Focusing on patient needs5. Testing and measuring effects of change6. Peer learning25Quality Improvement: A Refresher

Dimensions of qualityTechnical QualityProvider perception ofquality of HIV care26Quality Improvement: A RefresherExperiential QualityConsumer perceptionof quality of HIV care

Quality improvement principlesFundamental concept of improvement:“Every system is perfectly designed to achieve exactly the results itachieves.”Principles of improvement:1. Understanding work in terms of processes and systems2. Developing solutions by teams of providers and patients3. Focusing on patient needs4. Testing and measuring effects of change5. Peer learning27Quality Improvement: A Refresher

Linking PDSAs to performance measuresTheories/Ideas/Best practicesVery smallscale test28Quality Improvement: A RefresherFollowup testTest newconditionsLarge-scaletestChanges thatlead toimprovement

The Model for Improvement (PDSA)29Quality Improvement: A Refresher

The Model for Improvement (PDSA)What are we tryingto accomplish?How will we knowthat a change is animprovement?What change can wemake that will result inimprovement?30Quality Improvement: A Refresher

The Model for Improvement (PDSA)What are we trying toaccomplish?How will we knowthat a change is animprovement?What change can wemake that will result inimprovement?31Quality Improvement: A Refresher

The Model for Improvement (PDSA)What are we trying toaccomplish?How will we knowthat a change is animprovement?What change can wemake that will result inimprovement?32Quality Improvement: A Refresher

PROBLEM: What is the problem or gap we’ve identified in our system?AIM:What process oroutcome are wetrying to improve?33ACT Do we adopt, adapt, orabandon the change? What needs to be modifiedbefore the next PDSAcycle? What should the nextPDSA cycle test?STUDY Analyze all data, and summarizelessons learned. Did the change result in measurableimprovement?Quality Improvement: A Refresher PLANWhat change are we testing?Who are we testing the change on?When are we testing?Where are we testing?What data do we need to collect?Who will collect the data?When will the data be collected?Where will the data be collected?DOWhat was done to implement the change?Was the change implemented as planned?What where the barriers toimplementation?Was the change acceptable to staff andpatients?PDSAMEASUREMENT:How will we knowthat a change willresult inimprovement?

PROBLEM: Incorrect contact information in patient care booklet, leading to difficulties physically ortelephonically tracing loss-to-follow-up clients.AIM:We aim toimprove loss-tofollow-up rates byupdating contactinformation andtracing LTFUclients34ACT The change was adapted. The next PDSA will enlist2 additional CHWs toassist in updating clientcontact information, andoutcomes will be remeasuredPLANWhat: Update contact information in70 patient care bookletsWho: 1 community health worker willupdate client contact informationWhere: Clinic registration areaWhen: One week, March 1-7, 2017DOSTUDY 1CHWfromProjectHOPE was assigned Between March 1-7, 2017, only 3 (4%)to update contact informationof the expected 70 patient care Barriers to implementation included lowbooklets were updatedrapport between CHW and some clients; Rates of loss to follow-up pending inpoor documentation of updatedAprilinformation; existing workload of CHWQuality Improvement: A RefresherPDSA 1MEASUREMENT: Number ofpatient carebooklets withupdated contactinformation Proportion ofactive caseloadthat is LTFU

PDSA 1120%Target: 70updated PCBs57%4%1 CHW toupdatecontactdetails35Quality Improvement: A RefresherFollowup testTest newconditionsLarge-scaletest

PROBLEM: Incorrect contact information in patient care booklet, leading to difficulties physically ortelephonically tracing loss-to-follow-up clients.AIM:We aim toimprove loss-tofollow-up rates byupdating contactinformation andtracing LTFUclients36ACT The change was adapted. The next PDSA will enlistthe entire clinic team toassist in updating clientcontact information, andoutcomes will be remeasuredSTUDY Between March 8-14, 2017, only 40(57%) of the expected 70 patient carebooklets were updated Rates of loss to follow-up pending inAprilQuality Improvement: A RefresherPLANWhat: Update contact information in70 patient care bookletsWho: 3 community health workers willupdate client contact informationWhere: Clinic registration areaWhen: One week, March 8-14, 2017DO 3 CHWs from Project HOPE and TCE wereassigned to update contact information Barriers to implementation included lowrapport between CHWs and some clients;poor documentation of updatedinformation; some clients providingfalse informationPDSA 2MEASUREMENT: Number ofpatient carebooklets withupdated contactinformation Proportion ofactive caseloadthat is LTFU

PDSA 2120%Target: 70updated PCBs57%4%1 CHW toupdatecontactdetails37Quality Improvement: A Refresher3 CHWsto updatecontactdetailsTest newconditionsLarge-scaletest

PROBLEM: Incorrect contact information in patient care booklet, leading to difficulties physically ortelephonically tracing loss-to-follow-up clients.AIM:We aim toimprove loss-tofollow-up rates byupdating contactinformation andtracing LTFUclients38ACT The change was adopted The change wasimplemented and an SOPwas drafted for updating ofpatient contact informationPLANWhat: Update contact information in70 patient care bookletsWho: Entire clinic team will updateclient contact informationWhere: Clinic registration areaWhen: One week, March 15-21, 2017DOSTUDY Entireclinicteamwas assigned to update Between March 15-21, 2017, 90contact information(129%) of the expected 70 patient carebooklets were updated Rates of loss to follow-up pending inAprilQuality Improvement: A RefresherPDSA 3MEASUREMENT: Number ofpatient carebooklets withupdated contactinformation Proportion ofactive caseloadthat is LTFU

PDSA 3120%Target achieved!Target: 70updated PCBs57%4%1 CHW toupdatecontactdetails39Quality Improvement: A Refresher3 CHWsto updatecontactdetailsEntire clinicteam to updatecontact detailsSOP drafted,Large-scalechange adoptedtestinto routinepractice

Change adopted120%Continue monitoring to ensuresustained improvementTarget: 70updated PCBs57%4%1 CHW toupdatecontactdetails40Quality Improvement: A Refresher3 CHWsto updatecontactdetailsEntire clinicteam to updatecontact detailsSOP drafted,Large-scalechange adoptedtestinto routinepractice

Quality improvement in simple termsUnderstanding variation Systems thinking Voice of the patient: user experience Continuous cycles of measurement to assesseffect of changes 41Quality Improvement: A Refresher

Programming for Quality Improvement inHIV/AIDS:Are lessons from two decades of QI implementation in low- and middle-income countriesexportable to National TB Programs?Bruce D. Agins, MD MPH;Director, HEALTHQUAL Institute for Global HealthSciencesUniversity of California, San Francisco

Overview44 The problem: bridging the “know-do” gap to achieve HIV epidemic control The task: building health system capacity to sustainably assess, assure, andimprove quality The execution: learning to implement quality management programming inlow- and middle-income countries The way forward: implementing and sustaining HIV quality management in theera of UHCUCSF-HEALTHQUAL

The “know-do” gap“Health care interventions that are known to work and save lives arenot being implemented for every patient every time. We must addressthis gap between knowing and doing.”What we knowThe know-do gap – how what weknow differs from what we doWhat we doWe need to do the right things, in the right places, at the right time.45UCSF-HEALTHQUAL

Closing the “know-do” gap46UCSF-HEALTHQUAL

Closing the “know-do” gapQualityof HIVcare47UCSF-HEALTHQUAL

Closing the “know-do” gapQIcapacity48UCSF-HEALTHQUAL

2018—Three key themes from the year of global quality reportsTheme 1: Poor quality of care imperils global efforts to achieveSustainable Development Goals.Theme 2: Health systems need to measure outcomesand what matters most to people.Theme 3: Assuring—and improving—thequality of care requires system-wide action: ashared vision of quality, a coordinated qualitystrategy, continuous learning, and a clearstructure of accountability.49UCSF-HEALTHQUAL

The problem: closing the “know-do” gap inHIV care to achieve epidemic control50UCSF-HEALTHQUAL

The global HIV response: great strides, lingering gapsSource: UNAIDS. 2018. Miles to go: closing gaps, breaking barriers, righting injustices51UCSF-HEALTHQUAL

The global HIV response: great strides, lingering gapsSource: UNAIDS. 2018. Miles to go: closing gaps, breaking barriers, righting injustices52UCSF-HEALTHQUAL

Applying QI to UNAIDS’ 95-95-95 targets95%53UCSF-HEALTHQUAL95% 95%

The global HIV quality responseFUTURE – SustainableQI structures requiringnational-level resourcesand ongoing adaptationto the changing needsof the epidemic2017 – QI routine but not necessarily coordinated. Demonstrationof improved results following QI interventions2015 – 2012 – Formal improvement methods introduced alongside multipleparallel donor-driven program initiatives targeting same results. Limited fundingdedicated to QI. Intensive doses of QI show results, but in isolation2005 – Limited QI knowledge and implementation54UCSF-HEALTHQUAL

The task: building health system capacity tosustainably assess assure, and improve quality55UCSF-HEALTHQUAL

A framework for system-wide action on quality56UCSF-HEALTHQUAL

Building the foundations of high-quality health systemsThe task: How do we structure these foundations so that theyare resilient, and consistently deliver outcomes that areequitable, efficient, and people-centered?57UCSF-HEALTHQUAL

HEALTHQUAL Model58UCSF-HEALTHQUAL

“Quality management (QM) is a structural umbrella over all processes andactivities related to QA and QI. QM is responsible for the coordination andfacilitation of these activities in an organization. Specifically, QM is involvedin the selection of health care quality personnel, the allocation of otherresources, the monitoring and evaluation of plans, and the launching ofimprovement teams.—World Health Organization (EMRO). 2004. Qualityimprovement in primary health care: a practical guide.59UCSF-HEALTHQUAL

Quality management—key program elements60UCSF-HEALTHQUAL

Embedding QM activities at all levels of the health system61UCSF-HEALTHQUAL

The execution: learning to implement qualitymanagement in LMICs62UCSF-HEALTHQUAL

Zimbabwe: QM planning and coordination63 HIV Quality Management Strategy developedthrough sector-wide engagement ofstakeholders by national program.Accompanying guide and training programestablished in conjunction with partners,defining expectations for HIV care andtreatment programs. Donor-supported HIV Quality ManagementProgram is led at national level andimplemented through integrated provincial anddistrict systems.UCSF-HEALTHQUAL

Viet Nam: linking facility, district, and provincial cadresNational staff Establishment of national TWG forHIVQUAL (Decision no 68/QĐ-AIDS) Provincial level: 30 quality management steeringcommittees 30 provincial TWGs 172 quality groups in hospitals/medicalcenters Source: Cosimi et al. BMC Health Serv Res. 2015;15:26964UCSF-HEALTHQUALDistrict HIV clinics are coached byprovincial coaching teams, who receivementorship and training in QIimplementation from national program staff

Guyana: Benchmarking for improvement65Visit twice CD4 duringinlast6 months 6 monthsWt forDevCTXHeight HeadARVAdherence Assessed forWt everyage plot milestone TempPulse BP eachprophylaxievery circ everyMedication Assessment active TBvisiteverys every each visit each visit 8%88%88%88%100%89%63%59%86%63%100%86%64%DOROTH BAILEY %83%100%50%0%0%0%94%94%96%UCSF-HEALTHQUAL

Thailand: HIVQUAL-T data, 2002-2011Yr20062007200820092010201166No.Caselist ,775 41,673701138,844 UAL

Bi-directional data feedbackPolicies,guidanceNATIONALvAggregation, analysis,actionPROVINCEDataAggregation, analysis,actionDISTRICTAggregation, interventions

Haiti: enabling data-driven improvement Système Intégré de Gestiond’Healthqual d’Haiti (SIGHH) offersa centralized platform to monitor HIVquality initiatives across multipledomains—QM program infrastructure,QI projects, QI coaching, CHWservice data, and performancemeasurement. ‘ Integration of data systems (SIGHH,M & E) enables national program totarget low-performing sites forfocused technical assistance andmentoring, and link facilityperformance to population healthdata.68UCSF-HEALTHQUALPerformance measurementQM programQI projectsQI coaching

Haiti: fostering continuous learning 69National forums are convened on an annual basis to share successful interventions, recognizetop performers, refresh QI knowledge, and troubleshoot implementation challenges.UCSF-HEALTHQUAL

New York, USA: involving consumers in policy70UCSF-HEALTHQUAL

Valuing the patients’ journeySource: Bond V, et al. 2019. “’Being seen’ at the clinic ” Health Place.71UCSF-HEALTHQUAL

Valuing the patients’ journeySource: Rao A, McCoy S. 2015. “Fostering behavior change for better health.” StanfordSocial Innovation Review72UCSF-HEALTHQUAL

Lao PDR: translating patient feedback into improvement Patient feedback is collected throughcomment boxes Summary analysis is shared with clinicstaff for translation into priorities for qualityimprovement Specific complaints are handled byleadership Information is shared with national qualityprogram and satisfies requirements forhealth care facilities as part of the “5Goods 1 Satisfaction” framework73UCSF-HEALTHQUAL

Namibia: building capacity for QI across all levelsREPUBLIC OF NAMIBIAMinistry of Health and Social ServicesQuality Management capacityBuilding Framework74UCSF-HEALTHQUAL

Malawi: supporting improvement through WhatsApp 75A WhatsApp group was created as partof a large-scale improvement initiative inBlantyre. Key objectives of the groupincluded: Provision of remote qualityimprovement coaching and oversight Scheduling of initiative events andcoaching visits Facilitation of peer learning andexchange related to QI and the HIVtreatment cascade Routine submission of performancemeasurement data Development of peer-drivenaccountability and encouragementUCSF-HEALTHQUAL

Viet Nam: supporting improvement through regionalcoaching networks 76National coaching program with gradualtransfer of technical support to provinces.National TWG meetings to discuss QIcoaching led by MOH.Frequency: 2-3 visits every 6 months,supplemented by monthly web-basedassistance.Coaching: Support the provinces and sites to developQM plans Monitoring QI implementation Site-level support for data collectionUCSF-HEALTHQUAL

Namibia: indicators, priorities and measurement cycles:A national quality improvement initiative addressing food insecurityINTERVENTIONS Training of HCWs on importance of issue & measuring -Health education to patients/clients (specifically on alcoholabuse ) Devise basic, simple food security screening tools Improve documentation system Reorganize patient flow to streamline assessment Identification of focal person to conduct assessments Referrals, documentation/follow-up of patients needing foodsupplementation to NGOs Arrange effective referral system Strengthen integration of social workers into care teams toassess food security Initiation of nutrition gardens Soup kitchen corners (nutritional education)77UCSF-HEALTHQUAL

Namibia: large-scale collaborative improvement78UCSF-HEALTHQUAL

Namibia: scale-up and spread for maximal impact Quality improvement collaborative (NAMPROPA) produced significant improvements in careengagement, viral load monitoring, and viral load suppression, and creation of an evidencebased package of interventions. This initiative is being scaled up nationwide across all ART sitestomaximizeimpact.for NAMPROPA ActivitiesScale-UpStrategyNAMPROPA3 Regions, 24 Facilities79UCSF-HEALTHQUALScale-Up Wave 13 Regions, 43 FacilitiesScale-Up Wave 214 Regions, 72 Faci

NAMPROPA: Results80About UCSF - Data Updated August 2017

Zimbabwe: results of ART4ALL81UCSF-HEALTHQUAL

Namibia: organizing stakeholders around LKNCVIntraHealthNamLiVEUCSFHEALTHQUAL

HIV quality improvement: further reading83UCSF-HEALTHQUAL

Implementation challenges 84Committed resources at national level: material and humanNever-ending staff turnoverLimited data system infrastructure and available to produce meaningfuland actionable dataLack of QI capacityShifting political landscapesInadequate knowledge management and peer learning platformsMultiple implementing partners supporting facilities: donor confusionCodification of the QM program with adequate resources in the Ministryof HealthUCSF-HEALTHQUAL

Aligning disease-specific aims with a shared vision of qualityHIV treatment targetShared visionof qualityNational HIV indicatorsSource: Champasak Provincial Hospital, Lao PDR85UCSF-HEALTHQUAL

The way forward: sustaining HIV qualitymanagement in the era of UHC86UCSF-HEALTHQUAL

A roadmap to sustainability87 Local vigilance with continuous monitoring National leadership and infrastructure: a formal quality management program Data-driven focus on responding to gaps and achieving outcomes Local cadres of quality professionals who have opportunities for ongoingtraining Organized knowledge management systems that engage professional andprivate sectors, fostering communities of practice and learning exchanges Donor management Integration of disease-specific quality initiatives with national frameworks,policies and strategiesUCSF-HEALTHQUAL

Coda: embedding QM activities at all levels of the healthsystem88UCSF-HEALTHQUAL

Universal health coverage without quality: an empty promise“Without quality, universal health coverage (UHC) remainsan empty promise [ ] Quality is not a given. It takesvision, planning, investment, compassion, meticulousexecution, and rigorous monitoring, from the national levelto the smallest, remotest clinic.”—Dr. Tedros Adhanom Ghebreyesus. “How couldhealth care be anything other than high quality?”Lancet Global Health. 2018;6(11):PE11140-E1141.89UCSF-HEALTHQUAL

Quality for all, not just quality for someHow can we apply lessons learned from guaranteeing highquality health care for people living with HIV to guaranteeinghigh-quality health care for all?90UCSF-HEALTHQUAL

AcknowledgementsMalawi: Andrew Likaka, Moses Enock, Mercy Jere, Irvine Mchacha, Laywell Nyirenda, Rose Nyirenda, Wezi Msungama,Nicole BuonoNamibia: Apollo Basenero, Hilaria Ashivudhi, Ndapewa Hamunime, Simbarashe Mpariwa, Jacques Kamangu, MireilleKakubu, Gram MutandiZimbabwe: Bekezela Khabo, Japhet MabukuHaiti: Nicasky Celestin, Margareth Jasmin, Nika-Nola Lamothe, Kurt Jean-Charles, BalanVietnam: VAAC, CDC-Vietnam, HAIVNThailand: BATS, TUCLao PDR: CHAS; CDCHEALTHQUAL: Joshua Bardfield, Michelle Geis, Julie Neidel, Joseph Murungu, Dan Ikeda, Richard BirchardNew York State Department of Health AIDS Institute: Leah Hollander, Susan Weigl, Daniel Belanger, NanetteMagnani, Daniel Tietz, Freda CorenHRSA: Suzy Jed, Katie O’Connor, Tracey Gantt, Harold Phillips91UCSF-HEALTHQUAL

36 Quality Improvement: A Refresher PROBLEM: Incorrect contact information in patient care booklet, leading to difficulties physically or telephonically tracing loss-to-follow-up clients. AIM: We aim to improve loss-to-follow-up rates by updating contact information and